Every patient must be counseled about the risks of HIV infection. Patients in long-term, monogamous relationships should be given the surgeon general's AIDS information pamphlet and be informed that the disease is spreading in the population. These persons are not at risk if their relationship is monogamous, but studies repeatedly demonstrate that a significant percentage of apparently long-term, monogamous relationships are neither. Sexually active patients who have multiple partners over a period of years or those whose partners are not exclusive are at increasing risk of contracting HIV. These patients must be counseled that methods of birth control other than condoms subject them to a substantial risk of HIV infection. The patient may choose to accept this risk, but the physician must be able to prove that the risk was assumed knowingly. The physician must carefully document that the patient was counseled about the risk of HIV infection, that HIV infection leads to AIDS in both mother and child, and that HIV is increasingly a problem for heterosexuals.An ethical question posed by HIV and contraceptive choice is the extent to which patient choice is swayed by physician recommendations. Many patients rely on their physician to let them know what is medically dangerous. If the physician tells them to give up bacon and eggs forever because their cholesterol is elevated but the same physician continues to renew their oral contraceptive prescriptions, the implicit message is that HIV is less of a threat than a greasy breakfast. This does not mean that physicians should refuse to prescribe oral contraceptives for woman who are not in long-term monogamous relationships. It does mean that the physician must take care that warnings about HIV are not lost in the general noise of good health tips and recommendations that are given each patient. Patients who engage in high-risk sexual activity must be helped to understand the seriousness of the threat of HIV infection. This information should be reiterated whenever contraception is discussed or a prescription for oral contraceptives is refilled. ACOG: Technical Bulletin 136, Ethical Decision-Making in Obstetrics and Gynecology. (Nov 1989).
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